Blastomycosis in 64 Wisconsin Children: Unanticipated Infection Risk and Severity in Urban Residents.

BACKGROUND: Blastomycosis, an endemic mycosis of immunocompetent individuals, is typically seen after exposure to waterways within rural wooded regions. It is not considered a disease of urban environments. Infection can be solely pneumonic or disseminate to skin, bone or central nervous system. Unknown factors influence disease acquisition and severity in children. METHODS: We analyzed acquisition risks and disease characteristics of blastomycosis in children seen at a tertiary care center from 1998 to 2018 to identify potential exposure sources, measure disease severity and assess the effect of race upon disease severity. RESULTS: Of 64 infected children, mean age was 12.9 years, with median time to diagnosis 38.5 days. About 72% were male, 38% resided in urban counties and 50% had typical environmental exposure. Isolated pulmonary infection occurred in 33 (52%). The remainder had evidence of dissemination to skin (N = 13), bone (N = 16; 7 clinically silent) and cranium (N = 7; 3 clinically silent). Infection was moderate/severe in 19 (30%). Two children (3%) died. About 79% of children with moderate/severe disease (P = 0.008) and 71% of urban children (P = 0.007) lacked typical environmental exposure. Comparing children from urban counties to other residences, 63% versus 5% were black (P < 0.001) and 71% versus 35% developed extrapulmonary dissemination (P = 0.006). Moderate/severe disease was seen in 7/17 (42%) black children but only 12/47 (26%) children of other races (P = 0.23). CONCLUSIONS: Blastomycosis, can be endemic in urban children in the absence of typical exposure history, have frequent, sometimes clinically silent, extrapulmonary dissemination and possibly produces more severe disease in black children.

Eosinophils: Friends or Foes?

The roles eosinophils are recognized to play in health and disease continue to evolve. Formerly, eosinophils were believed to fill a primary role in host defense against helminths, an intermediary one in the propagation of allergic conditions, and a pathologic one in clinical conditions characterized by systemic eosinophilia and eosinophilic infiltration of target organs. Eosinophils are increasingly understood to be positioned centrally within mammalian immune and inflammatory networks, possessing receptors for an array of inflammatory mediators and capable of producing numerous proinflammatory and homeostatic mediators. The concept has emerged that eosinophils play a major role in the modulation of allergic inflammation and in the repair of damaged tissues in diseases characterized by eosinophilic infiltration. Possible new emerging roles for eosinophils include neoplasm surveillance, tissue remodeling during puberty and pregnancy, and the restructuring of adipose tissue. The eosinophil granulocyte line appeared hundreds of millions of years ago during the evolutionary process and continues to be retained by all vertebrate species. This is strong evidence that although all the beneficial roles of eosinophils have yet to emerge, eosinophils, on balance, must be considered friends and not foes.

Rapid Therapeutic Response of Eosinophilic Meningoencephalitis in a Toddler With Baylisascaris procyonis Infection.

INTRODUCTION: Eosinophilic meningitis is an infrequently encountered condition. Baylisascaris procyonis (raccoon roundworm) infection, rarely diagnosed in North America, is a known cause of eosinophilic meningitis, often producing death or permanent neurologic damage. CASE REPORT: We recently encountered a toddler with geophagia and probable exposure to raccoon feces, who presented with eosinophilic meningitis and encephalitis, and was diagnosed with B procyonis infection and possible Toxocara co-infection. His marked peripheral eosinophilia and neurologic symptoms rapidly responded to corticosteroid and albendazole therapy. DISCUSSION: Since B procyonis infection is infrequently encountered, its diagnosis in the proper clinical and epidemiologic setting may not always be considered, resulting in a delay of appropriate therapy. Our patient, diagnosed and treated early in his course, demonstrated rapid clinical and laboratory improvement with anti-inflammatory and antiparasitic therapy. CONCLUSION: In cases of eosinophilic meningitis, infection with B procyonis should be routinely considered to allow timely institution of effective therapy for this unusual but potentially fatal or debilitating infection.

Fever of Unknown Origin in Childhood.

Childhood fever of unknown origin (FUO) is most often related to an underlying infection but can also be associated with a variety of neoplastic, rheumatologic, and inflammatory conditions. Repeated, focused reviews of patient history and physical examination are often helpful in suggesting a likely diagnosis. Diagnostic workup should be staged, usually leaving invasive testing for last. Advances in molecular genetic techniques have increased the importance of these assays in the diagnosis of FUO in children.

Group A beta streptococcal infections in children after oral or dental trauma: a case series of 5 patients.

Group A streptococcus (GAS) produces a variety of disease processes in children. Severe invasive diseases such as necrotizing fasciitis can result. Traumatic dental injuries are common in the pediatric population, although the role of dental injuries in invasive GAS disease is not well characterized. In this article, we describe our retrospective series of 5 cases of GAS infection following oral or dental trauma in children.

H1N1 hemagglutinin-inhibition seroprevalence in Emergency Department Health Care workers after the first wave of the 2009 influenza pandemic.

STUDY OBJECTIVE: The 2009 H1N1 pandemic (H1N1pdm) virus has been associated with high rates of asymptomatic infections. Existing influenza infection control policies do not address potential transmission through exposure to asymptomatic infected individuals in health care settings. We conducted a seroprevalence study of H1N1pdm infection to determine whether health care workers (HCWs) in the emergency department showed increased evidence of infection during the first wave of the pandemic than that previously reported in adults in the community. METHODS: Blood samples and demographic and clinical data were collected from eligible emergency department HCWs. Subjects' sera were tested for presence of antibodies specific for seasonal H1N1 and H1N1pdm viruses by hemagglutination-inhibition assay. RESULTS: One hundred eight subjects were enrolled, of which 20 (18.5%) were seropositive for H1N1pdm and 52 (48%) for seasonal H1N1. The median age of H1N1pdm-seropositive subjects was 32 years (range, 24-59 years). Of H1N1pdm-seropositive subjects, 35% were asymptomatic. Rates of H1N1pdm detection in HCWs (18.5%) were significantly higher than those observed previously in an identical age cohort in the community (2.6%, n = 262). CONCLUSIONS: The higher serodetection rates in adults observed in the current study suggest potentially significantly more frequent infections in HCWs than in the general population. Further investigations are needed to ascertain the relative incidence of influenza infections in HCWs and non-HCWs, to study influenza transmission by asymptomatic infected subjects and ascertain the burden of such transmission in health care settings.

Clinical and epidemiologic characteristics of children hospitalized with 2009 pandemic H1N1 influenza A infection.

BACKGROUND: In 2009, pandemic H1N1 influenza caused significant morbidity and mortality worldwide. We describe the clinical and epidemiologic characteristics of children and adolescents hospitalized for 2009 H1N1 infections in Milwaukee, Wisconsin from April 2009 to August 2009. METHODS: We conducted retrospective chart reviews of hospitalized patients with laboratory-confirmed 2009 H1N1 infections. Data on financial burden associated with these infections were obtained and analyzed. RESULTS: A total of 75 children hospitalized for 2009 pandemic H1N1 infections were identified; the median age was 5 years (range, 2 months-19.2 years); 56% were males; 56% were Non-Hispanic Blacks; and 75%had at least one underlying medical condition. Twenty-four percent had only upper respiratory symptoms. Bacterial coinfections occurred in 1.3%.All but one patient received antivirals, 80% of patients received antibacterials,18.6% were admitted to the intensive care unit, 6% required mechanical ventilation, 2.6% required extracorporeal membrane oxygenation,and 2.6% died. The total charges incurred for H1N1 influenza hospitalizations were $4,454,191, with individual charges being highest for children > 12 years of age. CONCLUSIONS: The majority of children with pandemic H1N1 influenza associated hospitalizations had uncomplicated illness despite the frequent presence of high-risk conditions in our patient population. Laboratory confirmed 2009 pandemic H1N1 influenza hospitalizations resulted in substantial health care and economic burden during the first wave of the pandemic in spring 2009.

Epidemiologic Observations from Passive and Targeted Surveillance during the First Wave of the 2009 H1N1 Influenza Pandemic in Milwaukee, WI.

The first wave of the 2009 influenza H1N1 pandemic (H1N1pdm) in Milwaukee, WI has been recognized as the largest reported regional outbreak in the United States. The epidemiologic and clinical characteristics of this large first wave outbreak from April 28(th) 2009-July 25(th) 2009, studied using both passive and targeted surveillance methodologies are presented. A total of 2791 individuals with H1N1pdm infection were identified; 60 % were 5-18 years old. The 5-18 year and 0-4 year age groups had high infection (1131 and 1101 per 100,000) and hospitalization (49 and 12 per 100,000) rates respectively. Non-Hispanic blacks and Hispanics had the highest hospitalization and infection rates. In targeted surveillance, infected patients had fever (78%), cough (80%), sore throat (38%), and vomiting or diarrhea (8%). The "influenza like illness" definition captured only 68 % of infected patients. Modeling estimates that 10.3 % of Milwaukee population was infected in the first wave and 59% were asymptomatic. The distinct epidemiologic profile of H1N1pdm infections observed in the study has direct implications for predicting the burden of infection and hospitalization in the next waves of H1N1pdm. Careful consideration of demographic predictors of infection and hospitalization with H1N1pdm will be important for effective preparedness for subsequent influenza seasons.

Introduction of a Novel Swine-Origin Influenza A (H1N1) Virus into Milwaukee, Wisconsin in 2009.

On 17 April 2009, novel swine origin influenza A virus (S-OIV) cases appeared within the United States. Most influenza A diagnostic assays currently utilized in local clinical laboratories do not allow definitive subtype determination. Detailed subtype analysis of influenza A positive samples in our laboratory allowed early confirmation of a large outbreak of S-OIV in southeastern Wisconsin (SEW). The initial case of S-OIV in SEW was detected on 28 April 2009. All influenza A samples obtained during the 16 week period prior to 28 April 2009, and the first four weeks of the subsequent epidemic were sub typed. Four different multiplex assays were employed, utilizing real time PCR and end point PCR to fully subtype human and animal influenza viral components. Specific detection of S-OIV was developed within days. Data regarding patient demographics and other concurrently circulating viruses were analyzed. During the first four weeks of the epidemic, 679 of 3726 (18.2%) adults and children tested for influenza A were identified with S-OIV infection. Thirteen patients (0.34%) tested positive for seasonal human subtypes of influenza A during the first two weeks and none in the subsequent 2 weeks of the epidemic. Parainfluenza viruses were the most prevalent seasonal viral agents circulating during the epidemic (of those tested), with detection rates of 12% followed by influenza B and RSV at 1.9% and 0.9% respectively. S-OIV was confirmed on day 2 of instituting subtype testing and within 4 days of report of national cases of S-OIV. Novel surge capacity diagnostic infrastructure exists in many specialty and research laboratories around the world. The capacity for broader influenza A sub typing at the local laboratory level allows timely and accurate detection of novel strains as they emerge in the community, despite the presence of other circulating viruses producing identical illness. This is likely to become increasingly important given the need for appropriate subtype driven anti-viral therapy and the potential shortage of such medications in a large epidemic.

Severe osteomyelitis caused by Myceliophthora thermophila after a pitchfork injury.

BACKGROUND: Traumatic injuries occurring in agricultural settings are often associated with infections caused by unusual organisms. Such agents may be difficult to isolate, identify, and treat effectively. CASE REPORT: A 4-year-old boy developed an extensive infection of his knee and distal femur following a barnyard pitchfork injury. Ultimately the primary infecting agent was determined to be Myceliophthora thermophila, a thermophilic melanized hyphomycete, rarely associated with human infection, found in animal excreta. Because of resistance to standard antifungal agents including amphotericin B and caspofungin, therapy was instituted with a prolonged course of terbinafine and voriconazole. Voriconazole blood levels demonstrated that the patient required a drug dosage (13.4 mg/kg) several fold greater than that recommended for adults in order to attain therapeutic blood levels. CONCLUSION: Unusual pathogens should be sought following traumatic farm injuries. Pharmacokinetic studies may be of critical importance when utilizing antifungal therapy with agents for which little information exists regarding drug metabolism in children.

Survival after treatment of rabies with induction of coma.

We report the survival of a 15-year-old girl in whom clinical rabies developed one month after she was bitten by a bat. Treatment included induction of coma while a native immune response matured; rabies vaccine was not administered. The patient was treated with ketamine, midazolam, ribavirin, and amantadine. Probable drug-related toxic effects included hemolysis, pancreatitis, acidosis, and hepatotoxicity. Lumbar puncture after eight days showed an increased level of rabies antibody, and sedation was tapered. Paresis and sensory denervation then resolved. The patient was removed from isolation after 31 days and discharged to her home after 76 days. At nearly five months after her initial hospitalization, she was alert and communicative, but with choreoathetosis, dysarthria, and an unsteady gait.

Increased diagnosis of Lemierre syndrome and other Fusobacterium necrophorum infections at a Children's Hospital.

OBJECTIVE: To assess the apparent increase in the diagnosis of Lemierre syndrome (LS) and other Fusobacterium necrophorum infections at a large children's hospital. Infections with F necrophorum ranged from peritonsillar abscess to potentially fatal LS. LS is an oropharyngeal infection characterized by septic thrombophlebitis of head and neck veins, complicated by dissemination of septic emboli to pulmonary and systemic sites. METHODS: Review of the medical and laboratory records was conducted of all patients who were seen at or admitted to the Children's Hospital of Wisconsin with the diagnosis of LS and/or isolation of F necrophorum from a clinical specimen between January 1995 and January 2002. RESULTS: During the 7-year period of the study, there was an increase in the isolation of F necrophorum from patients who were seen at Children's Hospital of Wisconsin, as well as the number of cases of LS. There was 1 isolation of F necrophorum from clinical specimens per year from 1996 to 1999, which increased to 10 isolates of the organism from January 2000 to January 2002. During the most recent period, January 2001-January 2002, 5 cases of LS were diagnosed, a distinctive entity not recognized previously at the institution. CONCLUSIONS: The cause for the recent increase in the number of serious infections caused by F necrophorum infection diagnosed at our institution is unclear but does not seem to be related to changes in microbiologic techniques or patient demography. We speculate that it could be attributable, in part, to alterations in antibiotic usage patterns in our region. Clinicians need to be aware of the increasing clinical importance of F necrophorum infections and the life-threatening nature of LS.

Mycoplasma hominis and Ureaplasma species brain abscess in a neonate.

We report an infant with a mixed Mycoplasma and Ureaplasma brain abscess who was successfully treated with intravenous doxycycline and erythromycin. Therapeutic concentrations of doxycycline were demonstrated in cerebrospinal fluid. This report is evidence of the potential for Mycoplasma and Ureaplasma to produce focal central nervous system infection, as well as meningitis, in neonates and that use of doxycycline can be efficacious in the therapy of such infections.